Nokea
The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. Which statement by the father leads the nurse to determine he understood the instructions?
- A. If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest.
- B. If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body.
- C. If the baby turns blue, I will immediately put the baby upright in an infant seat.
- D. If the baby turns blue, I will put the baby in supine position with his head elevated.
Correct Answer: A
Rationale: In the event of a paroxysmal hypercyanotic or tet spell, the infant should be placed in a knee-chest position.
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A 4-year-old child presents to the clinic with a history of persistent dry cough and wheezing. What is the nurse’s primary concern?
- A. Allergic reaction
- B. Asthma exacerbation
- C. Respiratory infection
- D. Acute bronchiolitis
Correct Answer: B
Rationale: Wheezing and persistent dry cough are hallmark symptoms of asthma exacerbation, which is the nurse's primary concern.
Regarding a supracristal VSD, the following are true EXCEPT
- A. incidence is higher in Asian children
- B. complicated by aortic insufficiency in 50-90% of patients
- C. aortic insufficiency is most often not recognized until late in the lst decade of life
- D. murmur of a supracristal VSD is usually heard at the mid to upper left sternal border
Correct Answer: D
Rationale: Closure of asymptomatic supracristal VSDs at the time of diagnosis is not recommended.
A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet; swelling, redness, and restricted joint motion; and reports feeling fatigued. Which nursing diagnosis has the highest priority for this client?
- A. Pain related to joint inflammation
- B. Impaired physical mobility.
- C. Risk for infection.
- D. Disturbed sleep pattern.
Correct Answer: A
Rationale: Pain is the most immediate and distressing symptom for the client and should be addressed first to improve comfort and quality of life.
Patients at risk for bacterial endocarditis include those with all of the following EXCEPT
- A. repaired simple atrial septic defect
- B. aortic stenosis
- C. rheumatic fever heart disease
- D. palliative vascular shunts
Correct Answer: A
Rationale: Repaired simple atrial septal defects are not considered a risk for bacterial endocarditis unless there are residual defects.
A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow?
- A. Atrial septal defect
- B. Tetralogy of Fallot
- C. Ventricular septal defect
- D. Patent ductus arteriosus
Correct Answer: B
Rationale: Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis increases the pressure in the right ventricle, causing the blood to go from right to left across the ventricular septal defect. Atrial and ventricular septal defects and patent ductus arteriosus result in increased pulmonary blood flow.